Biomedical subjects
Publications and source records attributed to C M Sandler.
The scintigraphic findings on bone imaging in two patients with extensive lower extremity periostitis secondary to venous insufficiency are presented. One of these patients had bilateral disease. The use of [67Ga]citrate scanning in an attempt to exclude concurrent osteomyelitis is also addressed.
We treated 27 patients with iatrogenic ureteral injuries during a 6-year period. Gynecological operations were the most common antecedent surgical procedures (52 per cent). The diagnosis of ureteral injury was made immediately in 4 patients and was delayed 1 to 34 days in 23. Three of the 4 injuries recognized during an operation were repaired successfully at the time of injury; the primary repair in the remaining patient leaked and ultimately resulted in a nephrectomy. In the delayed diagnosis group retrograde ureteral catheterization was successful in only 1 of 20 attempts. Of the 23 patients with injuries recognized in the postoperative period 11 were managed successfully with percutaneous nephrostomy (with or without stenting) alone, 3 required surgical repair after temporary percutaneous nephrostomy drainage, 4 were treated surgically without prior nephrostomy drainage and 1 had spontaneous resolution of hydronephrosis. The remaining 3 patients required nephrectomy: 1 because of a urinary fistula in a previously irradiated field, 1 because of a concomitant (ipsilateral) renal cell carcinoma and 1 because of renal hypertension. Percutaneous nephrostomy or ureteral stenting was successful as primary therapy in 73 per cent of the patients in whom it was used.
During a 7 year period, we have seen 111 patients with bladder rupture, 95 from blunt trauma and 16 due to penetrating injuries. All 16 patients with penetrating injuries, as well as an additional 34 patients with intraperitoneal injuries, nine patients with extraperitoneal injuries, and five with both intra- and extraperitoneal injuries from blunt trauma, had formal closure of the wound and urethral or suprapubic catheter drainage. All did well. A total of 39 patients with extraperitoneal bladder injuries were treated with only catheter drainage and all did well. Eight patients died before institution of therapy.
Clinical and radiologic findings in 97 patients with bladder injury secondary to blunt pelvic trauma were reviewed. Fifty-five patients had extraperitoneal bladder rupture; 35, intraperitoneal rupture; two, interstitial bladder injury; and five, combined intraperitoneal and extraperitoneal bladder rupture. Of the 61 of 97 patients with film studies available for review, two patients with surgically proved intraperitoneal rupture had false-negative cystograms. In two other cases of intraperitoneal rupture, the diagnosis was established with cystography but was not demonstrated with urography. All cases of extraperitoneal rupture were demonstrated cystographically; in 15 cases in this group, the injury was complex, with extravasation of contrast material beyond the confines of the perivesical space. In two additional patients, incomplete bladder injury termed "interstitial bladder rupture" was identified. A classification of bladder injury based on cystographic patterns of extravasation is proposed.
With the widespread acceptance of ultrasonography and computed tomography for the evaluation of renal masses, the role of guided renal cyst puncture in the evaluation of a suspected renal cyst has undergone revision in recent years. In this article, the authors review the technique, interpretation, and complications of diagnostic cyst puncture and attempt to define its current diagnostic and therapeutic indications.
The double-J ureteral catheter has been popularized as an ideal internal ureteral stent. Migration of the distal end of the catheter up the ureter, however, can complicate its safe removal. A safe, controlled method of stent extraction is described using a C-arm fluoroscopic unit.
We report 3 cases of extraperitoneal bladder rupture in the absence of pelvic girdle disruption. The existence of this injury suggests that a mechanism other than that classically described for an extraperitoneal rupture is present. An etiology analogous to an intraperitoneal bladder rupture is proposed. It is suggested that in some patients this alternative mechanism is responsible for the bladder injury even in the presence of a coexisting pelvic fracture.
The use of percutaneous endourological techniques is demonstrated in recipients of renal allografts. Transplant complications that previously had required prompt surgical intervention may be approached safely by the judicious use of percutaneous manipulations. While examples of perirenal hematoma, renal abscess, urinary fistula and renal pelvic stone extraction are presented, close patient observation and a low threshold for surgical intervention are recommended to permit the continued, safe evaluation of this approach.
Intravenous digital subtraction angiography (IV-DSA) combined with excretory urography was used to evaluate the renal anatomy of 100 potential living-related kidney donors. Each of the 100 patients underwent subsequent nephrectomy to verify the number and distribution of renal vessels. For the entire series, 71 patients had bilateral single, 2 bilateral multiple and 27 multiple renal arteries on one side determined by angiography. Eleven patients required standard catheter angiography due to inadequate IV-DSA studies. Four patients who had a single artery imaged by IV-DSA were found to have an additional vessel at the operation. The overall accuracy of IV-DSA to identify the number of renal vessels was 96% (85/89). The sensitivity of the exam was 100% (94/94) and the specificity was 67% (4/6). It is concluded that IV-DSA combined with excretory urography is a safe, cost effective, and suitable method to image the renal anatomy of potential kidney donors. Thus about 90% of donors can be spared the risks and inconvenience of standard angiography, and the donor evaluation can now be performed on an outpatient basis.
The development and refinement of computed tomography have revolutionized the diagnostic evaluation of patients in urologic practice. This article reviews the applications and interpretation, as well as the limitations, of renal computed tomography and compares this modality with other imaging studies of the kidney.
Three straightforward radiologic examinations are the cornerstone of the diagnosis of a wide variety of urinary tract pathology that may be encountered in the emergency department. This article reviews some technical aspects of the examinations, the radiologic findings, and some controversial aspects of the diagnosis and subsequent management of these patients.
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Two patients developed anaplastic myeloma associated with prominent extramedullary disease one and four years after the initial diagnosis of multiple myeloma. Most tumor cells in the extramedullary sites were primitive-appearing and anaplastic, although plasmacytoid differentiation was evident. One patient had concurrent bone marrow involvement by cytologically similar cells, while the other patient was in bone marrow remission when he developed clinically evident soft tissue infiltration. Immunoperoxidase staining showed similar cytoplasmic immunoglobulin in both the mature-appearing and anaplastic cells in both patients. Electron microscopy in both cases showed a morphologic spectrum between the mature-appearing and anaplastic cells. DNA flow cytometric studies following the onset of extramedullary disease revealed a tumor cell population with a high degree hyperdiploid abnormality and unusually high proliferative activity in both cases, consistent with the morphologic anaplasia. Anaplastic myeloma appears to represent a distinct, aggressive variant of multiple myeloma which may result from a transformation of well differentiated myeloma cells to poorly differentiated immunoblast-like cells.
Digital subtraction angiography was used in 10 renal allograft recipients with sustained hypertension after transplantation to detect transplant renal artery stenosis. Recipients with end-to-end vascular anastomoses were visualized adequately in the anteroposterior projection. Two cases of transplant renal artery stenosis were identified by digital subtraction angiography and then verified by catheter angiography. Patients with end-to-side vascular anastomoses may require additional oblique projections. Digital subtraction angiography is a safe, noninvasive and cost-effective screening procedure to diagnose transplant renal artery stenosis in most recipients. Catheter angiography can be applied more selectively to those recipients with stenosis observed by digital subtraction angiography or when more detailed imaging is required.
During a 4-year 9-month interval 51 patients were seen with ruptured bladders. Of these patients 42 had suffered blunt trauma: 19 intraperitoneal, 22 extraperitoneal and 1 combined intraperitoneal and extraperitoneal injury. All patients with intraperitoneal injuries, 5 with extraperitoneal injuries and the 1 with combined injury were treated successfully by exploration, débridement, formal closure and catheter drainage. Of the patients with extraperitoneal injuries 16 were treated successfully by catheter drainage alone.
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The value of computed tomography (CT) in patients with severe renal inflammatory disease has not been previously emphasized. This paper presents the authors' experience using this modality in 17 patients with acute intrarenal inflammatory conditions. A spectrum of various renal abnormalities and their CT appearance ranging from lobar nephronia (focal pyelonephritis) to xanthogranulomatous pyelonephritis is presented. These cases demonstrate that CT provides more precise anatomic information than does urography and is helpful in distinguishing uncomplicated patterns of renal infection from other types of renal inflammatory disease. In this way, patients who may be managed medically can be differentiated from those who require surgical intervention.